Remote Investigative Auditor Jobs (NOW HIRING)

• Create and update audit plans, including identifying potential risk areas within hospital-payer contracts and outlining methodologies for identifying those risks within claims data.
• Review insurance payments and supporting documentation, including provider contracts, medical records, payer policies, and federal or state regulations, to determine payment accuracy and identify reimbursement opportunities.
• Research, analyze, and summarize underpayment issues, financial impacts, reimbursement trends, and recommended actions.
• Identify contractual and clinical reimbursement risk areas across commercial and government payors, including Medicare, Medicaid, coordination of benefits, workers' compensation, and other specialized audit areas.
• Develop specifications and procedures to identify and troubleshoot contractual, coding, and administrative underpayment risks using Excel, Access, SQL, and other analytical tools.
• Conduct reviews of zero-balance hospital accounts to identify underpaid inpatient and outpatient claims.
• Model reimbursement methodologies and create or maintain pricing documents used to calculate expected payments, including percent of charge, per diem, MS-DRG, outlier/stop-loss, implants, drugs, Medicare, Medicaid, outpatient reimbursement methodologies, and other payment structures.
• Work collaboratively with data analysts and project teams to develop, validate, and enhance pricing models and audit methodologies.
• Leverage technical tools and automation opportunities to improve audit efficiency and consistency.
• Present findings, processes, methodologies, and recommendations through clear documentation and reporting.
• Recommend improvements to internal processes, audit methodologies, and client contract administration processes.
• Research emerging reimbursement trends, regulatory changes, and payer practices and communicate findings to internal stakeholders.
• Other duties as assigned.

In addition to the responsibilities listed above, Senior Auditors may:

• Independently lead complex audit projects and reimbursement investigations.
• Identify new audit opportunities and reimbursement risk areas.
• Serve as a subject matter expert on contract interpretation, reimbursement methodologies, and regulatory requirements.
• Mentor, train, and support less experienced auditors.
• Develop and maintain training materials and deliver educational sessions.
• Provide technical guidance and quality review of audit work.

• High School Diploma or equivalent required.
• Bachelor's degree in a related field or equivalent experience preferred.

• Minimum 3 years of experience working with large healthcare data sets.
• Minimum 2 years of experience in research and analysis.
• Minimum 2 years of experience with managed care contracts and hospital reimbursement.
• Minimum 2 years of experience working with inpatient claims.
• Minimum 1 year of experience working with Medicare, Medicaid, and/or outpatient facility claims.
• Minimum 1 year of experience with contract modeling.
• Ability to translate complex contract language and healthcare data into actionable insights.
• Ability to work independently to solve problems and recommend technical solutions.
• Intermediate Excel skills, including complex formulas, functions, and pivot tables.
• Basic knowledge of Access and SQL preferred.
• Strong organizational, analytical, written, and verbal communication skills.
• Strong attention to detail.

• Minimum 5 years of experience working with large healthcare data sets.
• Minimum 5 years of experience in research and analysis.
• Minimum 3 years of experience with managed care contracts and hospital reimbursement.
• Minimum 3 years of experience working with inpatient and outpatient claims.
• Minimum 2 years of experience with contract modeling.
• Demonstrated ability to lead complex audits and reimbursement investigations.
• Ability to mentor, train, and develop staff.
• Advanced ability to interpret complex contract language and translate findings into actionable recommendations.
• Ability to develop technical solutions and process improvements independently.
• Intermediate to advanced Excel skills, including complex formulas, functions, pivot tables, and lookups.
• Basic knowledge of Access and SQL preferred.
• Strong organizational, analytical, written, and verbal communication skills.
• Strong attention to detail.